Safety-Net Providers After Health Care Reform

Ku, Leighton; Jones, Emily; Shin, Peter; Byrne, Fraser Rothenberg; Long, Sharon K.

doi:10.1001/archinternmed.2011.317

Cited by 91 publications

(99 citation statements)

References 5 publications

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“…1517 Other studies attempted to isolate the effect of gaining insurance by assessing "natural policy experiments" in which individuals gained cover age because of a policy change, rather than a potentially confounding life event. 9,1822 For example, studies of Massachusetts' 2006 expansions found that patients who gained coverage used ambulatory care services at higher rates postcoverage. 9,1921 This body of quasiexperimental research is based on the assumption that the observed changes in outcomes are caused by a change in insur ance status and not due to unmeasured confounding variables.…”

Section: Introductionmentioning

confidence: 99%

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Community Health Center Use After Oregon's Randomized Medicaid Experiment

DeVoe

Gold

Hoopes

et al. 2015

The Annals of Family Medicine

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PURPOSEThere is debate about whether community health centers (CHCs) will experience increased demand from patients gaining coverage through Affordable Care Act Medicaid expansions. To better understand the effect of new Medicaid coverage on CHC use over time, we studied Oregon's 2008 randomized Medicaid expansion (the "Oregon Experiment"). METHODSWe probabilistically matched demographic data from adults (aged 19-64 years) participating in the Oregon Experiment to electronic health record data from 108 Oregon CHCs within the OCHIN community health information network (originally the Oregon Community Health Information Network) (N = 34,849). We performed intent-to-treat analyses using zero-inflated Poisson regression models to compare 36-month (2008-2011) usage rates among those selected to apply for Medicaid vs not selected, and instrumental variable analyses to estimate the effect of gaining Medicaid coverage on use. Use outcomes included primary care visits, behavioral/mental health visits, laboratory tests, referrals, immunizations, and imaging. RESULTSThe intent-to-treat analyses revealed statistically significant differences in rates of behavioral/mental health visits, referrals, and imaging between patients randomly selected to apply for Medicaid vs those not selected. In instrumental variable analyses, gaining Medicaid coverage significantly increased the rate of primary care visits, laboratory tests, referrals, and imaging; rate ratios ranged from 1.27 (95% CI, 1.05-1.55) for laboratory tests to 1.58 (95% CI, 1.10-2.28) for referrals. CONCLUSIONSOur results suggest that use of many different types of CHC services will increase as patients gain Medicaid through Affordable Care Act expansions. To maximize access to critical health services, it will be important to ensure that the health care system can support increasing demands by providing more resources to CHCs and other primary care settings. Ann Fam Med 2015;13:312-320. doi: 10.1370/afm.1812. INTRODUCTIONT he Patient Protection and Affordable Care Act (ACA) created health insurance coverage options for millions of people in the United States. 13 It is predicted that ACA insurance expansions will lead to increased demand for primary care services by those gaining coverage. 46 Community health centers (CHCs) currently provide primary care and other critical services to many uninsured patients likely to be affected by the ACA. For example, in 2012, CHCs provided care to an estimated 21 million patients; 36% of these patients were uninsured and 40% were covered by Medicaid.7 It is unknown whether ACA expansions will affect use of CHCs. Some postulate that individuals who gain Medic aid will increase their use of CHCs, contrary to other assumptions that the newly insured will go elsewhere. 813Predictions of individuals' increased health care demand after gaining insurance are based on studies showing an association between coverage and better access to health care.14 Most of these previous studies examined coverage gains that occurred as a result...

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Section: Introductionmentioning

confidence: 99%

“…9,1921 This body of quasiexperimental research is based on the assumption that the observed changes in outcomes are caused by a change in insur ance status and not due to unmeasured confounding variables.…”

mentioning

confidence: 99%

Community Health Center Use After Oregon's Randomized Medicaid Experiment

DeVoe

Gold

Hoopes

et al. 2015

The Annals of Family Medicine

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“…6,11,12,15,71 Our findings come at a time when safety-net providers are caring for a sizeable portion of the newly insured population under the ACA, 72,73 while being underresourced and financially strained. 16,74,75 Notwithstanding the $11 billion the ACA committed for CHC expansion over 2010-2015, 34 the continuing financial challenges faced by safety-net providers may compromise access in low-income communities and undermine the quality of care by thwarting these institutions' ability to innovate in service delivery, improve quality, and participate in accountable care organizations.…”

Section: Discussionmentioning

confidence: 86%

Neighborhood Socioeconomic Status and Primary Health Care: Usual Points of Access and Temporal Trends in a Major US Urban Area

2016

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Neighborhood socioeconomic status (SES), an overall marker of neighborhood conditions, may determine residents' access to health care, independently of their own individual characteristics. It remains unclear, however, how the distinct settings where individuals seek care vary by neighborhood SES, particularly in US urban areas. With existing literature being relatively old, revealing how these associations might have changed in recent years is also timely in this US health care reform era. Using data on the Philadelphia region from 2002 to 2012, we performed multilevel analysis to examine the associations of neighborhood SES (measured as census tract median household income) with access to usual sources of primary care (physician offices, community health centers, and hospital outpatient clinics). We found no evidence that residence in a low-income (versus high-income) neighborhood was associated with poorer overall access. However, low-income neighborhood residence was associated with less reliance on physician offices [−4.40 percentage points; 95 % confidence intervals (CI) −5.80, −3.00] and greater reliance on the safety net provided by health centers [2.08; 95 % CI 1.42, 2.75] and outpatient clinics [1.61; 95 % CI 0.97, 2.26]. These patterns largely persisted over the 10 years investigated. These findings suggest that safety-net providers have continued to play an important role in ensuring access to primary care in urban, low-income communities, further underscoring the importance of supporting a strong safety net to ensure equitable access to care regardless of place of residence.

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“…4 Just such an increase in demand for community health centers was observed after the expansion of insurance coverage in Massachusetts. 11 As community health centers across the nation see more patients, the need for access to subspecialty care is likely to increase, too.…”

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confidence: 99%